Atrial Fibrillation Begets Heart Failure and Vice Versa: Temporal Associations and Differences in Preserved Versus Reduced Ejection Fraction

Rajalakshmi Santhanakrishnan, Na Wang, Martin G Larson, Jared W Magnani, David D McManus, Steven A Lubitz, Patrick T Ellinor, Susan Cheng, Ramachandran S Vasan, Douglas S Lee, Thomas J Wang, Daniel Levy, Emelia J Benjamin, Jennifer E Ho, Rajalakshmi Santhanakrishnan, Na Wang, Martin G Larson, Jared W Magnani, David D McManus, Steven A Lubitz, Patrick T Ellinor, Susan Cheng, Ramachandran S Vasan, Douglas S Lee, Thomas J Wang, Daniel Levy, Emelia J Benjamin, Jennifer E Ho

Abstract

Background: Atrial fibrillation (AF) and heart failure (HF) frequently coexist and together confer an adverse prognosis. The association of AF with HF subtypes has not been well described. We sought to examine differences in the temporal association of AF and HF with preserved versus reduced ejection fraction.

Methods and results: We studied Framingham Heart Study participants with new-onset AF or HF between 1980 and 2012. Among 1737 individuals with new AF (mean age, 75±12 years; 48% women), more than one third (37%) had HF. Conversely, among 1166 individuals with new HF (mean age, 79±11 years; 53% women), more than half (57%) had AF. Prevalent AF was more strongly associated with incident HF with preserved ejection fraction (multivariable-adjusted hazard ratio [HR], 2.34; 95% confidence interval [CI], 1.48-3.70; no AF as referent) versus HF with reduced ejection fraction (HR, 1.32; 95% CI, 0.83-2.10), with a trend toward difference between HF subtypes (P for difference=0.06). Prevalent HF was associated with incident AF (HR, 2.18; 95% CI, 1.26-3.76; no HF as referent). The presence of both AF and HF portended greater mortality risk compared with neither condition, particularly among individuals with new HF with reduced ejection fraction and prevalent AF (HR, 2.72; 95% CI, 2.12-3.48) compared with new HF with preserved ejection fraction and prevalent AF (HR, 1.83; 95% CI, 1.41-2.37; P for difference=0.02).

Conclusions: AF occurs in more than half of individuals with HF, and HF occurs in more than one third of individuals with AF. AF precedes and follows HF with both preserved and reduced ejection fraction, with some differences in temporal association and prognosis. Future studies focused on underlying mechanisms of these dual conditions are warranted.

Keywords: atrial fibrillation; epidemiology; heart failure; mortality; ventricular function, left.

© 2016 American Heart Association, Inc.

Figures

Figure 1
Figure 1
Temporal association of AF and HF subtypes. Panel A shows data for 995 participants with new HF, and whether participants had previous, concurrent, future AF, or no AF (for 479 with HFpEF: 154, 88, 56, and 181, respectively; for 516 with HFrEF: 121, 94, 67, and 234, respectively). Panel B shows data for 1737 participants with new AF, of whom 1101 had no HF (n=1101), and others had previous, concurrent, or future HF (for 284 with HFpEF: 57, 88, 139, respectively; for 272 with HFrEF: 67, 94, 111, respectively; for 80 with unclassified HF: 21, 32, and 27, respectively).
Figure 1
Figure 1
Temporal association of AF and HF subtypes. Panel A shows data for 995 participants with new HF, and whether participants had previous, concurrent, future AF, or no AF (for 479 with HFpEF: 154, 88, 56, and 181, respectively; for 516 with HFrEF: 121, 94, 67, and 234, respectively). Panel B shows data for 1737 participants with new AF, of whom 1101 had no HF (n=1101), and others had previous, concurrent, or future HF (for 284 with HFpEF: 57, 88, 139, respectively; for 272 with HFrEF: 67, 94, 111, respectively; for 80 with unclassified HF: 21, 32, and 27, respectively).
Figure 2
Figure 2
Cumulative incidence of AF and HF among those with and without the other condition. Panel A displays cumulative incidence of AF (N=795) in participants with and without prevalent HF. Panel B displays cumulative incidence of HFpEF (N=215) and HFrEF (N=272) in participants with and without prevalent AF. For 95% confidence interval estimates, please see Supplemental Table 5.
Figure 2
Figure 2
Cumulative incidence of AF and HF among those with and without the other condition. Panel A displays cumulative incidence of AF (N=795) in participants with and without prevalent HF. Panel B displays cumulative incidence of HFpEF (N=215) and HFrEF (N=272) in participants with and without prevalent AF. For 95% confidence interval estimates, please see Supplemental Table 5.
Figure 3
Figure 3
Kaplan Meier curves for all-cause death in those with HF and AF. Panel A displays cumulative incidence of all-cause mortality (N=598) after new HF by AF status. Panel B displays cumulative incidence of all-cause mortality after new AF (N=683) by HF subtype status. For 95% confidence interval estimates, please see Supplemental Table 5.
Figure 3
Figure 3
Kaplan Meier curves for all-cause death in those with HF and AF. Panel A displays cumulative incidence of all-cause mortality (N=598) after new HF by AF status. Panel B displays cumulative incidence of all-cause mortality after new AF (N=683) by HF subtype status. For 95% confidence interval estimates, please see Supplemental Table 5.

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